Behavioral Modification, Low-Dose Anti-Depressants, Not Surgery, May be Appropriate for Most Patients with Acid Reflux

As the number of Americans with acid reflux grows, a study by researchers at the University of Colorado Anschutz Medical Campus suggests noninvasive interventions like behavioral interventions and low-dose antidepressants are appropriate for most patients with gastroesophogeal reflux disease (GERD) that does not respond to PPI therapy, while only certain subgroups of patients should be referred for surgery.

“When you have a subset of patients who are not responding to drug therapy you need to respond in a thoughtful way,” said the study’s lead author, Rena Yadlapati, MD, MHS, assistant professor of medicine-gastroenterology at the University of Colorado School of Medicine. “Only a select few should be referred to surgery.”

Currently, about 30 percent of the U.S. population suffers from gastroesophageal reflux disease (GERD) and most are treated with drugs like Nexium known as a proton pump inhibitors. Yet for 10-40 percent of patients, medication doesn’t eliminate symptoms. And for some, a hypersensitivity to symptoms may lead them to believe their acid reflux is worse than it is.

Dr. Yadlapati and her colleagues surveyed a panel of 14 gastroenterologists on treatment options when typical acid reflux drugs don’t work. They constructed a number of hypothetical scenarios involving patients who did not respond to double dose proton pump inhibitors.

“A nuanced understanding of both the literature and the patient’s unique physiologic profile is critical to appropriate decision-making, as inappropriate recommendations may compromise outcomes and patient safety,” Yadlapati said.

The panel investigated each hypothetical case and ranked the appropriateness of four invasive anti-reflux options. They also ranked their preference for drug and behavioral health treatment options.

“In the majority of cases, an invasive anti-reflux intervention was ranked as an inappropriate option,” the study said.

For patients with true refractory acid reflux demonstrated by ongoing abnormal esophageal acid exposure despite proton pump inhibitors more invasive options were recommended like laparoscopic fundoplication, where part of the stomach is wrapped around the lower end of the esophagus and stitched into place.

The researchers found that some patients who didn’t respond to acid reflux drugs had a hypersensitivity to the symptoms. In these cases, Yadlapati said, invasive procedures are unlikely to improve outcomes while possibly increasing morbidity, decreasing quality of life and adding up to higher health-care costs.

She said low-doses of antidepressants have a role in modulating symptoms.

“Behavioral modification and relaxation therapy are also potentially effective,” she said. “In a study of nine patients with functional heartburn, esophageal-directed hypnotherapy was associated with significant improvements in symptoms, visceral anxiety and quality of life.”

Ultimately, Dr. Yadlapati said, treatment options should be personalized for each patient. Surgery may be called for in some cases but it’s not usually the preferred option.

“We are not opposed to surgery for the right patients,” she said. “But we should not be reflexively referring patients for these invasive treatments before considering all of the options.”